Community health workers for pandemic response: a rapid evidence synthesis

Input in CHW programmes during pandemic responses

Myriad inputs and planning were required to ensure effective pandemic response through CHWs. These are summarised in subdomains below:

• Policies related to CHW task/roles. Policies and guidance related to specific roles and tasks for CHWs were reported in many studies.9 21 30 34 37 38 These policies largely aimed to distinguish tasks as essential (routine activities that need to be continued but with modifications for decreased transmission risk), non-essential (non-essential activities that could be postponed) and additional activities that need to be carried. New roles and tasks for CHWS pertaining specifically to pandemic control varied immensely. This included community awareness (related to disease risk factors and symptoms, appropriate preventive practices and countering stigma), engagement and sensitisation,8 12 16 18 21 22 25 28 29 31–37 42 contact tracing,21 22 24 25 32 visiting sick or grieving community members,10 targeted community surveillance for prevention using one-health approaches7 and data collection to understand the impact of a pandemic26 in LMICs. In USA, they were engaged for better risk communication to high-risk groups.41 The other two studies from high-income countries did not indicate specific CHW roles.

• The WHO’s guidance on contact tracing recommends contact identification and listing to be conducted by a trained epidemiologist or surveillance officer, while contact follow-up might be done through CHWs.38 However, polices to involve CHWs in aspects of contract tracing had been developed and implemented during EVD, but their appropriateness is not well understood.21 22 24 25 It has further been noted that CHWs had completely abandoned their routine unpaid malaria case management duties over preferences to the paid contact tracing work.23 Changes in policies and standards of procedures for routine service delivery (eg, ‘no-touch’ policies for community level screening and treatment) were also reported.25 32 37 Policies for defining CHW roles were reported to be crucial for the purpose of bringing accountability and building trust in health systems, although this was not discussed more specifically.

• Logistics and funding for CHW programmes. Disruptions in drug and equipment supplies were common during pandemics and policies and mechanisms to address them from an early phase of the outbreak were reported to be important.5,10,16 In addition, shortfalls in routine supportive supervision methods may be expected. Sustained investments in CHWs were required during pandemic response including revisiting financial investments (discussed subsequently) for optimal outcomes.34 Issues in relation to financial incentives for CHWs are further discussed in section on CHW motivation and well-being.

• Governance and stakeholders. A wide range of stakeholders in the community needed to be engaged. The evidence base on stakeholder engagement is mostly from LMICs with existing CHW programmes where they were additionally engaged for COVID-19 activities and has been discussed in a subsequent domain on community support.

• Information management systems for CHWs in pandemics. Operational support using information management systems and digital health technology were reportedly used for supporting and monitoring CHW programmes. Honesty, transparency of communication and reciprocity of information with CHWs were noted to be beneficial.9 14 21 Many studies reported that pandemics impacted supervision and support for CHWs and health management information systems. Disease surveillance systems (reliant on passive reporting from health facilities) became almost entirely non-functional in some cases.36 43 In Vietnam, a new community based surveillance component was developed, in which CHWs played a critical role.22 CHWs recorded their daily activities in registers, and their reports were collated by the peripheral health unit supervisor and entered electronically, which formed the basis of information reaching the Ministry. The requirement to travel long distance to attend supervision meetings, health worker shortage, facility closures, restrictions on movement and increased prioritisation pandemic work were identified as key challenges for routine supervision and health information systems management.25 37

Programmatic process and health systems were crucial for effective service delivery by CHWs during pandemics.

Supportive systems, development, competency and well-being for CHWs

CHWs and their supervisors required appropriate training and supportive supervision for community sensitisation, awareness and risk communication during pandemic outbreaks, and the lack of these was noted as a significant barrier to effective service delivery.7 9 13 16–18 20 21 25 29 32 34 37 38 40

The nature, content and modality of training during pandemic varied immensely depending on context and specific role carved out for CHWs: as such what constitutes appropriate training for CHW might be very context specific. Components of training programmes reported focused on:

• Changes in protocols for existing service delivery pertaining to screening or managements.

• Education and awareness on the pandemic disease condition for CHWs.

• For generating awareness, risk communication and community sensitisation strategies on the pandemic condition to key client groups of CHWs or as in the area they served completely.

• Disease surveillance, contact tracing and outbreak response.

• Transportation and management of suspect or confirmed cases of those affected by the pandemic disease condition.

• Use of personal protective equipment (PPE) and other infection control practices.

• Rebuilding community relationships postoutbreak.

In most of these studies, it was reported that appropriate training in skills and knowledge related to disease outbreaks led to an improvement in awareness of the disease, screening and reporting. In qualitative studies, it was reported that training changed in perceptions of CHWs, leading to more proactive involvement in disease prevention and control. In Sierra Leone, for instance, the Mobile Training and Support programme (an e-health training for CHWs on pandemics) used a decentralised reporting structure with outreach to individual CHWs and was reported to be useful.29 Appropriate training helped CHWs overcome fear and become more confident about providing and delivering care and helped them deal with a broad range of challenges. Transparency in communication that included sharing of information from supervisors motivated CHWs to be involved and mitigated the fear frequently encountered during pandemics.

CHWs were reported to be at an increased risk of exposure due to lack of or insufficient or incorrect usage of PPE.10 18 19 40 In previous disease outbreaks, training sessions on pandemic preparedness were focused on protocols, and the use of appropriate and adequate PPE, during patient care. There is some evidence that training and availability of PPE resulted in CHWs being more confident to cope with managing the disease outbreak.10 13 16 17 20 40 42

During previous pandemics, CHWs have faced stigmatisation, isolation and in some cases were even socially ostracised.15 33 37 The studies reported that communities often saw them as ‘carriers for infection’ owing to the proximity (real or perceived) with those affected by the outbreaks as well as high mortality rates among healthcare workers in general. CHWs often isolated themselves to protect their ‘loved ones’ from disease and stigma. As noted in the subsequent section, availability of PPE boosted confidence in CHWs but its effect on community perceptions about CHWs has not been studied.

CHWs used several coping strategies including peer support, finding renewed purpose in continuing to serve the community and turning to religion to guide strength.15 None of the studies reported preparedness to mitigate well-being for CHWS, but post facto efforts like peer and family support (praying together before work or through social media platform like WhatsApp) were reported to enhance CHW well-being.15 Furtherore, workshops that provided emotional support and ways to deal with the social stigma helped CHWs cope with seeing patients and colleagues dying from the disease. Studies reported that improved working conditions, provision of housing allowance, equal training opportunities, transportation/remote area allowance (or provision of bicycles in rural areas), and improved salaries (paid on time and for a broad range of services), awards in high-profile public events contributed to better recruitment and retention of CHWs during pandemics.13 15 16 33 34 Some studies also noted that CHWs often had to bear the cost on their own or even borrow money to provide services or medicines to those they served—acting as an important challenge for motivation.16 17

Support from community-based groups for community access and community-centred care

Community engagement and sensitisation were reported to address knowledge gaps related to disease outbreak and discourage discrimination and stigmatisation towards CHWs.15 33 Coercive laws against community members initiating discrimination and stigmatisation towards CHWs were not reported. Information sharing in the community as well as engagement of community leaders were reported to help build trust in CHWs, leading to better access as well as satisfactory experience in care received.8 28 33 35 37 Community elders and village heads should be engaged and involved to rebuild trust, leading to an increased use of services. We did not find any evidence pertaining to aspects of community support and access from high-income countries.

Community-level outputs and health outcomes of CHW-led pandemic response

A study noted that the social standing (in terms of social status) of CHWs empowered them in terms of their participation in pandemic responses.34 Community health policies for social mobilisation and community engagement strategies were found to build trust and increase utilisation of services, which were found to be useful in pandemic response.8 15 33 37 Engaging CHWs in the early phases of outbreaks potentially improved overall response procedures and adaptive resilience.34 It was reported that CHW-led programmes led to improved knowledge and awareness among farmers leading to improved motivation for reporting of avian influenza.7 In another study, it was noted that reporting for malaria by CHWs improved from 59% (preoutbreak) to 95% (during outbreak) and 98% (postoutbreak) owing to ‘sustained investments in CHWs through provision of incentives, supervision and provision of adequate reporting tools’.22 In general, training of CHWs led to improved knowledge, service quality and well-being, as has been noted in preceding sections. One study from rural Uganda reported that CHW-delivered psychosocial support to build community trust and confidence was often not available for disadvantaged and poor families owing to lack of accountability measures.12 As such, it is important to build adequate governance and reporting structures and use an equity-focused approach in programming.

Equity, gender, accountability and economic evaluations

We did not find any economic evaluations related to CHWs in pandemic responses. Issues around equity, gender and accountability were seldom studied, including in relation to the populations to whom CHWs provided their services. Specific equity-focused studies were scarce, but female CHWs had a different set of challenges, which has been discussed in an earlier section pertaining to CHW support and well-being.

Role of CHWS during a pandemic

Evidence from our RES pertains mostly to well-established government-run CHW programmes in LMICs. The implications of introducing new CHW programmes in the midst of a pandemic, as is being planned by the UK,44 are not well understood, but considerable challenges might be expected considering the larger body of literature around community trust and systems integration being critical for success.45–48

In countries with well-established CHW programmes, roles and tasks of CHWS change substantially during pandemics. There is a need to change the normal standards of procedures of conducting routine activities—as for example instituting ‘no-touch policy’. Relevant, tailored and continuously updated guidance, training and supportive supervision should be planned for. Most common additional activities for CHW during pandemics were community awareness, engagement and sensitisation (including for countering stigma) and contact tracing. However, when CHWs were involved in contact tracing, substantial reduction in delivery of routine but essential health service delivery took place. This is crucial considering the larger body of evidence from previous pandemics showing consequences on population health owing to disruption in routine service delivery.43 49 50 WHO Guidance mandates possible use of CHWs only for contact follow-up component of contact tracing.38 The bulk of the contact tracing work involves contact identification and listing, and it should be conducted by a separate trained cadre, as mandated by WHO. Effectiveness of different cadres for conducting contact tracing is beyond the scope of the RES. Yet, our evidence suggests that not involving CHWs in contact tracing may also safeguard essential primary healthcare service delivery, which is a key concern in any pandemic.

Key considerations for effectively mobilising CHW in a pandemic

There is a wide variation in CHW programmes in most countries in alignment with how they are defined and what they tasks they are allocated in normal times and in terms of their level of education and training, modality and degree of engagement with health system and remunerations they receive for the same.51 As such, in terms of practical decision making, the background context will determine considerations for effective CHW mobilisation during a pandemic. However, clear guidance on changed roles and tasks—vis-à-vis essential activities that need to be sustained (with modification), non-essential tasks that can be postponed and additional pandemic activities that need to be performed—is critical. As noted in our RES, disruption in supply chain, logistics and supportive supervision is expected and should be accounted for when guidance and training are being instituted. These apart, supportive structures related to governance, sustained financing and health information systems need to be carefully planned with built in strategies for course correction and updating in light of new information and developments. All these imply the need for training to be carefully planned and anticipating potential scenarios and consequent mitigation plans.

During previous pandemics, CHWs experienced stigmatisation, isolation and were socially ostracised, and the same might be expected during COVID-19 without appropriate investment and support the same. Governments should thus make provisions for psychosocial support in the form of peer support and professional help. While the RES does not provide any particular information pertaining to proactive approach to prevent stigmatisation of CHWs in the first place, general principles of antistigma programmes52 indicated community awareness and engagement can be key. As such engagement for and by CHWs with community leaders to develop culturally appropriate messages might serve the dual purpose of awareness for prevention as well as countering stigma. Futhermore, developing an a priori pandemic communication plan and engaging with CHWs and community leaders that aim to build trust, engage with affected populations, and integrate risk communication into health and emergency response systems would be useful .53 Our RES indicated that training and aavailability of PPE resulted in CHWs being more confident to cope with managing the disease outbreak. The effect of PPE availability for CHWs on communities is not reported. However, an effective health system which takes care of local CHWs might potentially build community trust in addition to ensuring CHW safety .

CHWs in most contexts, and as we found in most of the included studies, have a volunteer status without any base salary, long-term security or other employment benefits like retirement benefits, medical or life insurance.54 Performance-based incentives (financial or in-kind) leads to CHWs focusing more on tasks that are remunerated. As such, in pandemic, wherein many of the ordinarily remunerated, tasks are suspended and additional tasks are being allocated might be unsettling for CHWs. More broadly, recognition as staff and moving towards a base salary structure in alignment with the 2018 WHO recommendation against a performance-based incentive structure55 during a pandemic should be planned. This will not just be beneficial for health systems performance but is also imperative from a rights perspective. There is, however, need for more research on this domain. Provisions for additional transport allowance, accommodation and child support should also be considered owing to the need to protect families of CHWs from infection. Awards and recognition in a high-profile manner might also be useful.

In many countries most, if not all, CHWs are women and are subject to gender norms (domestic work being one example) as well as other gendered vulnerabilities and risks (like domestic violence).56–58 Sustained investment together with governance and information systems support for this cadre are important. Furthermore, as argued elsewhere, CHWs are part of a larger ecosystem of health system wherein ensuring trust and accountability is essential, more so during a pandemic.49